CAREWELL CARE SERVICES

CARE COORDINATION SERVICES AUTHORIZATION


Please read carefully, by proceeding you acknowledge and authorize the following:


I. Acknowledgement of Privacy Practices

I acknowledge that I have received or been provided access to the Carewell Care Services Notice of Privacy Practices, which explains how my health information may be used and disclosed in connection with Carewell’s care coordination services.


II. Authorization to Use and Disclose Information

I authorize Carewell Care Services to use and disclose my personal and health information, including protected health information, as necessary and appropriate, to:


  • Provide care coordination and care support services
  • Communicate with me and, if applicable, my authorized caregiver
  • Share information with Carewell’s service providers and partners who assist in delivering care coordination services on Carewell’s behalf


These service providers may include care coordinators, clinical staff, and technology or operational vendors, and are required to protect my information in accordance with applicable federal and state law.


III. Voluntary Participation

I understand that:

  • Participation in Carewell Care Services is voluntary
  • I may revoke this authorization at any time by notifying Carewell in writing
  • Revocation will not apply to information already used or disclosed based on this authorization prior to revocation


IV. Duration of Authorization

This authorization will remain in effect for the duration of my participation in Carewell Care Services unless it is revoked earlier.


V. No Conditioning of Services

I understand that Carewell Care Services will not condition treatment or services on my signing this authorization, except to the extent that the authorization is necessary to provide care coordination services requested by me.


VI. Electronic Consent

By selecting “I Agree,” responding affirmatively, or otherwise providing electronic confirmation, I acknowledge that this authorization is valid and legally binding. 


I have read and understand this Authorization and agree to its terms.



Name: _____________________________


Date: ______________________________